Referral Process
Referral forms to request Carlson services may be obtained from the student's school of residence or school of attendance, or may be downloaded at https://carlson.lausd.org/apps/pages/index.jsp?uREC_ID=3779259&type=d&pREC_ID=2446564
A complete copy of immunization records must accompany the referral for all students. For secondary students, a copy of the transcript and transfer grades should accompany the referral.
The Home Medical Referral form (Attachment A) is completed by the physician, DO, PA or NP, and the parent/guardian. For students who are first time LAUSD enrollees, prior to enrollment at Carlson, the
student is to register at the LAUSD school of residence so that a cumulative record and health card are established. The Home Medical Referral validity shall not exceed one year from the signature date of the referring physician, DO, PA or NP. For clarification regarding initial or continued eligibility for Carlson services, the Carlson school nurse may contact the physician, DO, PA or NP. If the physician, DO, PA or NP is unable to provide appropriate clarification, services or the extension of services may be denied.
student is to register at the LAUSD school of residence so that a cumulative record and health card are established. The Home Medical Referral validity shall not exceed one year from the signature date of the referring physician, DO, PA or NP. For clarification regarding initial or continued eligibility for Carlson services, the Carlson school nurse may contact the physician, DO, PA or NP. If the physician, DO, PA or NP is unable to provide appropriate clarification, services or the extension of services may be denied.
The Hospital Medical Referral form (Attachment B) is completed by the hospital attending physician/psychiatrist and the parent/guardian. Non-LAUSD students hospitalized at an acute hospital facility within LAUSD residential area are temporarily enrolled in LAUSD through Carlson and provided services. For students who reside at a sub-acute
care facility and are also first time LAUSD enrollees, prior to enrollment at Carlson, the student is to register at the LAUSD school of residence so that a cumulative record and health card is established. The Hospital Medical Referral shall remain valid for the duration of the student’s continuous hospitalization. For clarification regarding
initial or continued eligibility for Carlson services, the Carlson school nurse may contact the physician, DO, PA or NP. If the physician, DO, PA or NP is unable to provide appropriate clarification, services or the
extension of services may be denied.
The Psychiatric Referral form (Attachment C) is completed by the psychiatrist or primary physician, the school principal/designee, and the parent/guardian. The referral shall not exceed 90 days in length. If services are needed beyond 90 days, another referral form must be completed. The psychiatrist or primary physician’s signature is
required in order for the Carlson nurse to authorize services; the principal’s signature documents the accommodations that have been attempted at the student’s school of attendance. For students who are first time LAUSD enrollees, prior to enrollment at Carlson, the student is to register at the LAUSD school of residence so that a cumulative record and health card are established. A subsequent Psychiatric Referral will initiate notification to the cum carrying school to consider scheduling a Student Support and Progress Team (SSPT) meeting, or review of the current IEP or Section 504 Plan. For clarification regarding initial or continued eligibility for Carlson services, the Carlson school nurse may contact the physician. If the physician is unable to provide appropriate clarification, services or the extension of services may be denied.
required in order for the Carlson nurse to authorize services; the principal’s signature documents the accommodations that have been attempted at the student’s school of attendance. For students who are first time LAUSD enrollees, prior to enrollment at Carlson, the student is to register at the LAUSD school of residence so that a cumulative record and health card are established. A subsequent Psychiatric Referral will initiate notification to the cum carrying school to consider scheduling a Student Support and Progress Team (SSPT) meeting, or review of the current IEP or Section 504 Plan. For clarification regarding initial or continued eligibility for Carlson services, the Carlson school nurse may contact the physician. If the physician is unable to provide appropriate clarification, services or the extension of services may be denied.
The Non-Medical Referral for Interim Home Instruction form (Attachment D) is initiated by the school, signed by the
parent/guardian, and sent to the Associate Superintendent of the Division of Special Education, Local District Superintendent, Administrator of Operations, or their designee(s) on file for authorization. The referral shall not exceed 90 days in length. If services are needed beyond 90 days, another referral form must be completed. For clarification regarding initial or continued eligibility for Carlson services, the Carlson school nurse or administrator may contact the signatory. If the signatory is unable to provide appropriate clarification, services or the extension of services may be denied.
parent/guardian, and sent to the Associate Superintendent of the Division of Special Education, Local District Superintendent, Administrator of Operations, or their designee(s) on file for authorization. The referral shall not exceed 90 days in length. If services are needed beyond 90 days, another referral form must be completed. For clarification regarding initial or continued eligibility for Carlson services, the Carlson school nurse or administrator may contact the signatory. If the signatory is unable to provide appropriate clarification, services or the extension of services may be denied.
The completed referral form together with current immunization records should be faxed to (818) 505-0246, or sent to:
Carlson Home Hospital School
10952 Whipple Street
North Hollywood, CA 91602
10952 Whipple Street
North Hollywood, CA 91602